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FILE COPY <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ,�2z26( 5. oIn o�se �/Wy Assessors 7�y�r O/ <br /> WELL Locatio 1 ' L) ry Coss StreetGtfdn4 flu ity Tr Zip Parcel# 0?,C G-06 <br /> PROPE TY C <br /> Owner TY <br /> d� b(lian Mai dAd ress�75Z4 W-(nCQn4 �1111CRcity �r Zip IPhone# <br /> C-57 Contractor_rCSj hInll, C CGL Addressl01[k East I�alf(`A- citYA Il1h6mZip.qdkt6Lic#SIMCPhone# ( ��// ?Q 651) <br /> Consultant/Sub Cntr 5 PC( (- Address(000 acoad ly{1aQT i� ic# Phone# 5(0 -109 7[6 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# n OVER-BORE. DIAMETER <br /> A WELL# M(w]-1 M - a PRESSURE GROUT <br /> n*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE d." n MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS k- 4 Q TYPE OF CASING: a STEEL X'PVC a OTHER: <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> n AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER: 0 OTHER APPROX.BORING DEPTH O Ctf Q BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certifyt t I e prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin n s, u �lations, and all applicable California State Laws. SPL <br /> Signed x Title/Company � ��) 1 e-01— J/' L <br /> G <br /> Print Name I IN Date b�Z[to <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PSE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> '7lo 45V110 44 SR# 00 7D�Y_ <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />